After almost three years the Spanish investigators of the Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC) have published the final report of their investigation into the cause of the fatal accident involving a Spanair MD-82 at Madrid, Spain.

The MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain on August 20, 2008. Of the aircraft’s occupants, 154 were killed, including all six crew members, and 18 were seriously injured. The MD-82 aircraft operated Spanair flight JKK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA).

The CIAIAC has determined that the accident occurred because *):

The crew lost control of the aircraft as a result of a stall immediately after takeoff, when the plane was not configured correctly, with the flaps / slats not being deployed, following a series of failures and omissions, with the absence of a warning of the incorrect takeoff setting.
The crew did not identify the lack of warnings nor correct the situation after takeoff –momentarily retarding engine power levers, increasing the pitch angle and failure to correct the roll– deteriorating the flight conditions.
The crew did not detect the configuration error by not properly using the checklists containing items to select and check the position of flaps / slats in the work of flight preparation, namely:

No cross-checking was made of the position of the lever and the status indicator lights for flaps and slats during the “After Start” checklist;

Omission to check the flaps and slats under “Take Off Briefing” in the taxi checklist;

The visual inspection of the position of the flaps and slats at the point “Final Items” of the “Take Off Imminent” checks was not made, as shown by the instruments of the cockpit.

As contributory factors CIAIAC determined:

The absence of a notice of the incorrect takeoff configuration because the TOWS did not work and therefore did not alert the crew that the takeoff configuration of the aircraft was inappropriate. It was not possible to determine conclusively the cause why the TOWS system did not work.

Inadequate crew resource management (CRM), which did not prevent the diversion of procedures in the preparation of the flight.

*) The final report is currently available in Spanish. An English translation is being prepared by CIAIAC. In case of conflicting text, the Spanish text is valid.